Decipher Bone Marrow Results

[Danielle S]

I am hoping someone can help decipher the meaning of these bone marrow results.

Mildly hypercellular marrow with trilineage hematopoiesis and lymphoid aggregates. The biopsy shows scattered small, aggregates of mature lymphocytes, which is unusual at this age. No abnormal spindled mast cells are evident, and by immunohistochemistry, mast cell tryptase highlights rare scattered mast cells. Reticulin stain shows increased fibrosis (MF-2). CD3 and CD20 highlight a mixture of T and B cells within the lymphoid aggregates.
CD10 is essentially negative on the lynphocytes. Immunohistochemistry controls are examined and show appropriate reactivity

PERIPHERAL BLOOD SMEAR INTERPRETATION: Mild normocytic normochromic anemia.

Oncology BLD BM Chromosome Analysis
INTERPRETATION All but one cell analyzed contained a 46XX normal female karyotype. The remaining one cell contained 45 chromosomes with loss of one copy of chromosome 7 which was a non-clonal chromosome change

[barbarth]

I too am trying to understand terms in my bone marrow biopsy. Now that I'm typing an answer, I can't see your message, which is unhelpful. I'm far from expert, but I believe your biopsy says you're at stage two of myelofibrosis (out of four stages, I think). I'm sorry if I'm alarming your unneccessarily and hope you get good medical care from a specialist. There were a couple of other things I recognized from your excerpt, but can't see it and can't recall.

[Marrowforums]

Originally Posted by barbarth

Now that I'm typing an answer, I can't see your message, which is unhelpful.

Forum tips:

While you are composing your message, scroll down the page. You'll see Danielle S's message at the bottom of the page.

Another way to see Danielle S's message is to click the Quote button instead of the Post Reply button. Then the message will be right there in the same box where you type your reply.

[Jmonroe96]

I have an appointment next week to go over my results but I just figured I’d ask here since I’ve been confused about my results these past few days.

It says: Hypocellular. The myeloids are reduced in number with complete maturation. The erythroids are relatively increased in number with maturing forms present in colonies. The megakaryocytes are adequate in number and
distribution with a minor subset displaying mild dyspoietic features
including small size and hypolobation/monolobation. Scattered lymphocytes appear unremarkable.

Immunohistochemical and special stains:
CD34 highlights the myeloblasts, 1% of total marrow cellularity.
CD117 is positive in myeloblasts, other precursor cells, and mast
cells.
Iron is negative for storage iron.

[Matthew42]

Dear JMonroe96,

I hope you are well.

My mother has severe aplastic anemia and just had another bone marrow biopsy done last week. She is getting her results tomorrow from the doctor. Her doctor is concerned that her horse-ATG is not working after 15 weeks, even though her neutrophils got close to 1000 for a few weeks and she went 2 weeks without blood last month.

The biopsy was done to see if her cellularity has increased. But I read that higher cellularity doesn't always equate to higher hemoglobin/platelet/neutrophil levels. Who knows, really? My mother's hematologist is quite negative and follows everything with a "textbook" mindset. She initially told her that she could be transfusion-dependent for 6 months or so post-ATG, but now is acting like she should have been transfusion-independent at 12 weeks. Again, who knows? I've already been told that some doctors wait 9 months or more after horse-ATG to declare it ineffective. I can't see her hematologist waiting much longer before she declares it ineffective. She fails to understand that my mother started out with only 5% cellularity before beginning treatment, and that she is almost 70 years-old. My mother already knows that she is probably going to have to get a second opinion.

As far as your questions is concerned, I wish I could help you. I am very little knowledge about bone marrow biopsies, but nothing seems to stand out as negative from a bit of research I've done to understand aplastic anemia biopsies. You're just hypocellular. That's all that really stands out to this non-expert


Wishing you much health and happiness.

[Jmonroe96]

Thank you so much Matthew42! Im hoping and wishing things go well with your mother and that her hematologist changes their attitude to something more open and positive!

[Hopeful]

Hi Jmonroe96,

I am not a doctor or in the medical field but what stands out to me is that you have no iron stores. This will effect your body's ability to make blood. Your doctor will likely help determine the cause of your iron deficiency and recommend the best treatment.

Best of luck at your appointment!

[Hopeful]

Originally Posted by Matthew42

Dear JMonroe96,

I hope you are well.

My mother has severe aplastic anemia and just had another bone marrow biopsy done last week. She is getting her results tomorrow from the doctor. Her doctor is concerned that her horse-ATG is not working after 15 weeks, even though her neutrophils got close to 1000 for a few weeks and she went 2 weeks without blood last month.

The biopsy was done to see if her cellularity has increased. But I read that higher cellularity doesn't always equate to higher hemoglobin/platelet/neutrophil levels. Who knows, really? My mother's hematologist is quite negative and follows everything with a "textbook" mindset. She initially told her that she could be transfusion-dependent for 6 months or so post-ATG, but now is acting like she should have been transfusion-independent at 12 weeks. Again, who knows? I've already been told that some doctors wait 9 months or more after horse-ATG to declare it ineffective. I can't see her hematologist waiting much longer before she declares it ineffective. She fails to understand that my mother started out with only 5% cellularity before beginning treatment, and that she is almost 70 years-old. My mother already knows that she is probably going to have to get a second opinion.
.

Hi Matthew,

Please who respond at 3 months are considered early responders, and it is usually taken as a good sign. If her transfusions are getting farther and farther apart, that is a good sign. If any of her counts start rising, that is a good sign. In my opinion, any good sign is considered a response. It is a good idea to track her counts in a spreadsheet so you can view the trends. Be sure to note her transfusions and any drugs that she starts/stops.

I have been told that the counts will rise before you see improvement in the bone marrow cellularity. It takes a long time for the marrow to recover. The goal of the ATG is to stop the attack on the marrow so that it can recover.

If your mom's doctor doesn't seem hopeful or is considering changing her treatment or stopping cyclosporine, I would seek a second opinion first. It doesn't hurt to have two doctors. Sometimes they will work together, if your lucky

Your mom is lucky to have such a great advocate for her.

Wishing you both the best!

[Matthew42]

Originally Posted by Hopeful

Hi Matthew,

Please who respond at 3 months are considered early responders, and it is usually taken as a good sign. If her transfusions are getting farther and farther apart, that is a good sign. If any of her counts start rising, that is a good sign. In my opinion, any good sign is considered a response. It is a good idea to track her counts in a spreadsheet so you can view the trends. Be sure to note her transfusions and any drugs that she starts/stops.

I have been told that the counts will rise before you see improvement in the bone marrow cellularity. It takes a long time for the marrow to recover. The goal of the ATG is to stop the attack on the marrow so that it can recover.

If your mom's doctor doesn't seem hopeful or is considering changing her treatment or stopping cyclosporine, I would seek a second opinion first. It doesn't hurt to have two doctors. Sometimes they will work together, if your lucky

Your mom is lucky to have such a great advocate for her.

Wishing you both the best!

Thank you, Hopeful, for your kind response. I really do appreciate it.

Well, there has been a bit of an update since I last posted, as my mother saw her hematologist a few days ago. The doctor said that she is indeed responding to IST treatment as there was some improvement in bone marrow cellularity. Her neutrophils before ATG were around 400, but now average around 700. She said that neutrophils will rise way before hemoglobin and platelets. She went 14 days without a blood transfusion in July (normally she transfuses every 9 days or so). Sometimes there can be a sudden drop in levels for a week or two at times in the journey, but there should be an "upward trend" overall, even if levels drop suddenly at times.

All that said, her doctor said that there is real improvement from IST therapy, but she won't deem the treatment successful as her hemoglobin and platelets have not shown strong enough improvement. They are going to wait another two months before considering doing the rabbit. She said if the horse-ATG fails to bring her levels up in the coming months so she can get off blood transfusions, the rabbit-ATG should get her over the hump. They would give her even longer than two months, but her age is a concern (almost 70). All that said, a slow recovery can be a good thing, too, just like a too fast of recovery may not be a good thing. It's hard to say. She confirmed during this appointment that there are many patients who don't get off transfusions or show improvements until 6 months, sometimes even 9+. There are cases where it took almost 1-2 years for horse-ATG to work, but she said it's not safe to let my mother go down that road. She said there may be advantages to a slower recovery, but the risks are too high for older people to wait around. She insisted on my mother's age, over and over again. But, even if the horse-ATG ends up working, my mother will have had a slower recovery for sure.

She now has iron overload, but the doctor said that because she is in otherwise good health, not to get too excited over it. Lots of people have it and most get their levels down to below 1000 (which is acceptable). If she had a heart problem, it would be much more serious. It's also not been festering in her body for a long time, so that it is a good thing.

Also, getting off RBC transfusions is more important than platelets. Sometimes, platelets are last to come up, but not always.

She also said that you never know what aplastic anemia is going to do. For many people, they will just have ATG once or twice, and then go on to have no relapse or only minor relapses over a period of decades. Some will have major relapses over time and will have to have ATG several times; and some will have to stay on cyclosporine long-term. And a small portion of patients will never respond to IST and will require a BMT (these cases are less autoimmune, I believe). Once in a while, she said people have spontaneous remission without treatment, and the disease never comes back. She said it's a bizarre disease. You just never know!

The biggest positives for my mother were: higher neutrophils averaging over 500 for the past 6 weeks + a bit higher cellularity in bone marrow. She is positive about IST working, but can't guarantee the horse-ATG will do the trick in the next two months. She cannot wait, she said, because of her age. She also said that second ATG is no riskier than the first. Having 2 ATG's is no big deal. I am just saying what she said.

I forgot to mention that my mother's reticulocyte is now in the normal range. This is also evidence that she her bone marrow is now working much better. Just waiting for the hemoglobin and platelets to come up.

I am wishing you great health and happiness as well. Thanks again, Hopeful!

[Hopeful]

Originally Posted by Matthew42

Her neutrophils before ATG were around 400, but now average around 700. She said that neutrophils will rise way before hemoglobin and platelets. She went 14 days without a blood transfusion in July (normally she transfuses every 9 days or so). Sometimes there can be a sudden drop in levels for a week or two at times in the journey, but there should be an "upward trend" overall, even if levels drop suddenly at times.

All that said, her doctor said that there is real improvement from IST therapy, but she won't deem the treatment successful as her hemoglobin and platelets have not shown strong enough improvement. They are going to wait another two months before considering doing the rabbit. She said if the horse-ATG fails to bring her levels up in the coming months so she can get off blood transfusions, the rabbit-ATG should get her over the hump. They would give her even longer than two months, but her age is a concern (almost 70). All that said, a slow recovery can be a good thing, too, just like a too fast of recovery may not be a good thing. It's hard to say. She confirmed during this appointment that there are many patients who don't get off transfusions or show improvements until 6 months, sometimes even 9+. There are cases where it took almost 1-2 years for horse-ATG to work, but she said it's not safe to let my mother go down that road. She said there may be advantages to a slower recovery, but the risks are too high for older people to wait around. She insisted on my mother's age, over and over again. But, even if the horse-ATG ends up working, my mother will have had a slower recovery for sure.

She now has iron overload, but the doctor said that because she is in otherwise good health, not to get too excited over it. Lots of people have it and most get their levels down to below 1000 (which is acceptable). If she had a heart problem, it would be much more serious. It's also not been festering in her body for a long time, so that it is a good thing.

Also, getting off RBC transfusions is more important than platelets. Sometimes, platelets are last to come up, but not always.

The biggest positives for my mother were: higher neutrophils averaging over 500 for the past 6 weeks + a bit higher cellularity in bone marrow. She is positive about IST working, but can't guarantee the horse-ATG will do the trick in the next two months. She cannot wait, she said, because of her age. She also said that second ATG is no riskier than the first. Having 2 ATG's is no big deal. I am just saying what she said.

I forgot to mention that my mother's reticulocyte is now in the normal range. This is also evidence that she her bone marrow is now working much better. Just waiting for the hemoglobin and platelets to come up.

Hi Matthew42,

Is your mom on cyclosporine now? Also, did her doctor discuss Exjade (or equivalent) for her iron overload? Did your mom have Eltromobag initially? Has she had her EPO levels tested?

Has there been any rise in her hemoglobin or platelets? How frequent are her transfusions?

You can't rush the recovery from Aplastic Anemia unfortunately. You can stop the immune attack with ATG, or more slowly with cyclosporine, but the marrow can still take years to recover.

I remember my doctor wasn't happy with my response at 3 months as well and didn't think the ATG was working. However a few months later my platelets took a small step forward and the recovery began.

Stay positive!

[Matthew42]

Originally Posted by Hopeful

Hi Matthew42,

Is your mom on cyclosporine now? Also, did her doctor discuss Exjade (or equivalent) for her iron overload? Did your mom have Eltromobag initially? Has she had her EPO levels tested?

Has there been any rise in her hemoglobin or platelets? How frequent are her transfusions?

You can't rush the recovery from Aplastic Anemia unfortunately. You can stop the immune attack with ATG, or more slowly with cyclosporine, but the marrow can still take years to recover.

I remember my doctor wasn't happy with my response at 3 months as well and didn't think the ATG was working. However a few months later my platelets took a small step forward and the recovery began.

Stay positive!

Thank you! I appreciate your response.

Yes, she is still transfusion-dependent (blood and platelets). A few weeks ago, she went two weeks without a blood transfusion (her hemoglobin dropped much more slowly), but things are not like that now. She's back to every 7-9 days for RBC transfusions.

She saw her hematologist at the end of last week. There was some positive news: her bone marrow cellularity increased 5% (not much, but it's enough to know the ATG is working). She also has a reticulocyte count of > 30,000, so she said that bone marrow is indeed producing red blood cells, and ATG is working for sure. And her neutrophils are still averaging +500 over 6 weeks. The hematologist said that while this is all positive news, the levels don't always match improvement seen in bone marrow function; in fact, it can take the body a long time for higher levels of hemoglobin and platelets to be reflected after bone marrow function improvement is proven. I didn't know all of this. Yes, she said it can take years for bone marrow to completely heal from ATG (very shocking to find out), but she doesn't think my mother should wait real long because of her age to do a second ATG "to get her over the hump." She wants her off RBC transfusions in the next few months (she's not that concerned about platelet transfusions).

As far as iron overload, she said it's okay to let it be a for a while before treating it. She has no heart issues and gets weekly blood tests, and is otherwise healthy. Letting it fester for a long time (1 year or so) is when issues can start, unless the iron overload is already excessively high (+ 10,000). She's not against using natural means to lower ferritin levels. Also, Exjade is very potent, and she doesn't want her on it now.

Yes, my mother has been on cyclosporine for a few months.


Health and happiness to you!

[Hopeful]

Hi Matthew42,

You may want to use this time to get yet another opinion from an AA expert. Giving a second round of ATG may make sense if it was felt that the immune attack was still going on in full-force. I am not sure how they can definitively tell this though.

Having such frequent RBC transfusion is concerning. Is your mom fighting a virus now?

Has she been tested for PNH?

[Matthew42]

Originally Posted by Hopeful

Hi Matthew42,

You may want to use this time to get yet another opinion from an AA expert. Giving a second round of ATG may make sense if it was felt that the immune attack was still going on in full-force. I am not sure how they can definitively tell this though.

Having such frequent RBC transfusion is concerning. Is your mom fighting a virus now?

Has she been tested for PNH?

Well, the doctor never said that treatment was successful: she only said that ATG is working, but will it be enough in the coming months? There are signs that things are getting better, but there are no guarantees that this ATG will bring her over the hump. She said that my mother could wait several more months to see if the horse-ATG will work (because sometimes it can take over a year or so to get off RBC transfusions), but she doesn't want her on RBC transfusions that long because of her age and iron overload. This is the reason for wanting a second ATG so soon, if I understand the hematologist well.

She has had genetic testing, but everything has been normal thusfar (no PNH, etc.).

She has no infection at all. Her blood work has been perfect, except for low hemoglobin, platelets and neutrophils. It's all really bizarre.

I don't like her getting RBC transfusions every 7-9 days, but she has no choice. The doctor won't let her go under 7.5, but usually doctors don't transfuse to about 7.0 or under. If that had been the case, she would have had probably 2 or 3 less RBC transfusions so far since ATG.

She's had 11 RBC transfusions since ATG, which was administered 16 weeks ago. She averages about 3 RBC transfusions a month since ATG. In July, she almost made it with just 2, until the last day of the month. LOL.

They believe that my mother's aplastic anemia was brought on by 2 different medications, and then Covid-19 made it severe. They can't prove it, but that is the thinking. She is quite old for aplastic anemia, they said. They really scrutinized her bone marrow biopsies (had three). And everything came back each time: SAA.

That's all for now.

Please take care.

[Hopeful]

Hi Matthew42,

I just read some of your other posts. It is a waiting game at this point, which is never easy. It's good that your mom is seeing some improvements in her counts. If she is no longer taking the drugs that may have damaged her marrow and if she is recovered from COVID, then hopefully time and rest will allow her marrow to heal, and you will see incremental improvements in the coming weeks/months. Did she get convalescent plasma to fight her COVID? This seems like human-ATG to me.

I remember that only one blood line would improve at a time for me, and very slowly. I also remember a bump in my HGB right after ATG that quickly went back down. I remember having the talk at 3 months. I remember feeling stronger after ATG, even though it took awhile for this to be seen in my counts. Keep the faith and stay positive!

I think you can request fresh RBCs. This may help extend the length of time between transfusions. As you know, after ~20 bags of blood, iron overload is a concern.

Is your mom off of platelet transfusions? Is her platelet count holding, even if it is low?

Wishing you both well!

[Matthew42]

Originally Posted by Hopeful

Hi Matthew42,

I just read some of your other posts. It is a waiting game at this point, which is never easy. It's good that your mom is seeing some improvements in her counts. If she is no longer taking the drugs that may have damaged her marrow and if she is recovered from COVID, then hopefully time and rest will allow her marrow to heal, and you will see incremental improvements in the coming weeks/months. Did she get convalescent plasma to fight her COVID? This seems like human-ATG to me.

I remember that only one blood line would improve at a time for me, and very slowly. I also remember a bump in my HGB right after ATG that quickly went back down. I remember having the talk at 3 months. I remember feeling stronger after ATG, even though it took awhile for this to be seen in my counts. Keep the faith and stay positive!

I think you can request fresh RBCs. This may help extend the length of time between transfusions. As you know, after ~20 bags of blood, iron overload is a concern.

Is your mom off of platelet transfusions? Is her platelet count holding, even if it is low?

Wishing you both well!

I really do you appreciate your taking the time to give help. You're very helpful, Hopeful. As you know, you can't just talk about this disease with anyone, as it's so rare.

Maybe I wasn't being clear, but the reason my mother's hematologist is considering a second ATG instead of waiting 9 months or more is because she wants her off RBC transfusions because of iron overload, and just off of blood in general. Why? Well, her age, as I said, no matter if she's in good health or not. If she were much younger, she would be less concerned about letting her "wait it out" as long as possible. That's all. Of course, my mother can say no, and wait it out, and the doctor would accept that. We're going to wait another 2-3 months and see what happens.

Her platelets usually are at 12 or 14 seven days after one platelet transfusion. She used to be 8 or below. So, there is a tiny bit of an improvement on that front, I suppose.

Yes, she is off those medications, thank god. You want to know what they are? Naproxen and Restoril. Hematologists believe that they both contributed to her aplastic anemia, unfortunately. Both cause bone marrow failure. She abused Naproxen, but the her old doctor said 4 X 250mg was fine (1000 mg/day) for several years. Really??

My mother never had treatment for Covid-19 - she was left go. She only had a terrible sore throat and 2 weeks later: SAA, seriously. Unbelievable!

Wishing you great health.

Bye, bye.